FOCUS ON ENERGY CLAIM FORM
Focus on Energy offers rebates and instant discounts on a variety of energy-efficient heating and cooling equipment including furnaces, boilers, smart thermostats, and water heaters. Rebates offered on eligible equipment.
DEALER INFORMATION
Company Name
*
First and Last Name
*
Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Zip Code
*
Email
*
Phone (Main)
*
Please enter a valid phone number.
CONSUMER INFORMATION
Consumer / Business Name
*
Installation Date
*
-
Month
-
Day
Year
Date
Installation Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Zip code
*
Note
INSTALLATION INFORMATION
Building Type
*
Project Type
*
Gas Utility Provider
*
Existing System Fuel Type
*
Electric Utility Provider
*
Gas Service Account Number
Electric Service Account Number
AHRI # / Source Identifier
*
EQUIPMENT INFORMATION
Equipment Purchase Date
*
-
Month
-
Day
Year
Date
Quantity
*
Product Type
*
Serial Numbers
*
Manufacturer
*
Model
*
Equipment Sell Price
*
Instant Discount Amount
*
DISTRIBUTOR INFORMATION
Distributor Company Name
*
Distributor Invoice Number
*
Submit
Should be Empty: